Mommy Makeover Made (Mostly) Easy [Part 2]

Announcer (00:02):
You are listening to Alabama the Beautiful with cosmetic surgeon, Dr. James Koehler and Kirstin Jarvis.

Kirstin (00:08):
Okay. We're back with part two of our mommy makeover session and we're going to talk about recovery. So being prepared for recovery is super important and you might have the best results in the world, but if you're not mentally and physically prepared for recovery, you'll probably not have the greatest experience. So I am going to start with another patient review. Are you ready for this one?

Dr. Koehler (00:33):
Okay, go for it.

Kirstin (00:34):
Okay. Dr. Koehler himself was completely honest about what to expect. He didn't promise unrealistic outcomes and he didn't try to upsell me on procedures that weren't necessary. His main priority is truly the patient and their needs and safety education is important to Dr. Koehler as well. He doesn't mind questions, encourages them even, or get aggravated about even the simple ones. He's relatable and very easy to talk to. As far as aftercare, it's the best I've had with any other cosmetic surgery I've had with other physicians. I wonder why they don't do the things he suggests and I'll never have another procedure anywhere else.

Dr. Koehler (01:12):
Oh, that's cool. I hadn't heard that one. That's a good one.

Kirstin (01:15):
What do you think she was referring to when she said, I wonder why they don't do the things he suggests. What is different that you do?

Dr. Koehler (01:22):
Well, I mean, I will tell you the one thing I think that we are good at, and I really have to applaud my staff here, is that we've had discussions and I've told my nurses this plenty of times. I'm like, look, the time we spend upfront with our patients is extremely valuable because if you mentally prepare them for what they're going to expect and they know what they're supposed to do and how to take care of things, they're still going to have questions after surgery. They always do because this is all new to them. It's not new to us, but it's new to the patient. But the more time that we can educate and get them up to speed upfront really saves us time on the flip side, and it relieves the patient anxiety. And so I think the one thing that my nurses are really good about doing is taking that extra time at the preoperative appointment to make sure that the patient really understands the preoperative instructions, what they need to do prior to surgery, but then also after care what to expect and what to do.

(02:32):
And then of course we've got a list of supplies to get and things to do and all that. But if people have planned for their surgery, the things they need to get before their surgery, then it's really not a big deal. I mean, yes, recovery is a big deal, but they're mentally prepared and then they have the people in place to help them. They know what kind of help they're going to need for how long they're going to need it, all of those things. And so there's simple things that we would all just take for granted and especially us because we do it every single day. So it's like common sense. Well, yeah, obviously you'd need this, but it's not to the patient. So we try to do a good job with that.

Kirstin (03:12):
Yeah, I agree. We just did some nurse interviews earlier in the week and one thing that Sarah wanted to make sure she reiterated to these potential nurses was a lot of the job is education and we just want to make sure that we explain things thoroughly to patients because that's kind of what Dr. Koehler is known for. So that was one big thing that she wanted to make sure they were aware. We want you to take good care of the patients no matter the time of day we're going to answer all their questions. So I really love that about this place.

Dr. Koehler (03:42):
The other thing that made me think about what you were saying there is that it's not when you're educating those patients, like the problems that people can have after surgery, complications, infections, and things like those are rare things, but that's why patients doing all the right things, minimizes all those things. There are things that patients can do that will decrease the likelihood of problems after surgery. And it's on the patient. We could do everything, but if they're not doing certain things the way they're supposed to do, they can still have some issues. So it's a team sport here. We both have to do our part.

Kirstin (04:21):
For sure, but our patient outcomes, yes, we talked about recovery in the first episode of our mommy makeover saga. So let's dive a little bit deeper into recovery. You said people will feel better after a couple weeks, but then after six weeks they can start getting into things like exercise and back to normal activities.

Dr. Koehler (04:42):
Really at the six week point from breast or tummy surgery. At that point, I feel like the patient's healed enough to where they're not going to tear anything or wreck anything. Those are the concerns. People say, I don't want to wreck what you did. I mean, you'd have to really go out of your way at six weeks to do something like that because your body's going to tell you if you try to start exercising now at six weeks, there's going to be moments where your body's going to be like Uh-uh not quite ready. And so you modify and

Kirstin (05:15):
You should stop when your body says that.

Dr. Koehler (05:16):
Yes, absolutely. And you modify, but you can start doing things you wouldn't want to be. And I get this, I know I've got my little workout routine and I don't like to miss. It's like that is my time and I don't book anything there I don't want to do. That's my time. And I got my routine and I like it and I want to keep it that way. So I totally get it When I have patients that come in and they're like into fitness and health and they're like, what do you mean I can't work out for six weeks? I mean, what am I going to do for six weeks? That's impossible. I can't do this. I'm like, you can do it. So there's two things. First of all, why do we say six weeks? Well, unfortunately, and it's rare, but I have seen it before.

(06:01):
Somebody two weeks out from surgery straining doing something way too much. And I've seen hematoma two weeks out from surgery where something started to bleed because they did something too much. Now that's not common. It's pretty rare, but it's certainly possible. And we don't want to overdo things like the suture's holding everything together. Your body doesn't have scar tissue in place to hold things, so you got to be careful. So for those people out there that are listening that are like, I like my exercise routine, this is what I tell everybody, I'm like, if you're into fitness, everybody tells you this. 80% of it is the nutrition. Anyhow, the nutrition is way more important than the actual exercise. I know the exercise makes you feel good, you get that rush from doing it, but if you're worried about your health, the nutrition is a big part. And so what I try to emphasize, I say, look, if for six weeks I wouldn't let you exercise, but I would pose this challenge to you, you eat the cleanest you've ever eaten, you meal prep, you do all of these things that maybe in your life, it's like that's like you, maybe you're not as good at that because you can get away with it working out so much. So focus your attention on the meal prep and the nutrition part, and then when you can then hit back to the gym.

Kirstin (07:24):
Yeah. It's an investment. So you might as well do the right thing to take care of your investment.

Dr. Koehler (07:29):
Yeah. Well, I know, and some people think they know better or the classic is, well, that won't happen to me. It could and you can't chance it. We'd give these instructions for a reason. We didn't just arbitrarily make 'em up.

Kirstin (07:43):
When somebody is recovering from, and we will just for this instance, call mommy makeover, like a breast lift and augmentation in a tummy tuck, maybe some lipo. How long would somebody need help say this mommy makeover, we've got little kids at home. Does my husband need to take off work for six weeks? Or how long will I need help around the house?

Dr. Koehler (08:04):
How long do you want 'em to take off for?

Kirstin (08:06):
Oh, 24 hours.

Dr. Koehler (08:09):
<laugh> Oh God.

Kirstin (08:09):
I'm kidding. <laugh>

Dr. Koehler (08:11):
I'm calling him up. Geez.

Kirstin (08:12):
I'm just kidding.

Dr. Koehler (08:14):
No, I mean that varies. You need help for sure. The first week you need somebody around the first week doing all of that breast lift, augmentation, tummy tuck. I mean, you're not going to need after maybe a couple of days, it's not like you're going to need somebody at your bed right there waiting for you. But when you get up out of a bed or try to get up, you're going to need some assistance. You don't want to strain your muscles. Somebody's going to have to grab your arm, help lift you up. You're going to be able to walk. It's not like you're an invalid, but when you stand up, you might feel a little lightheaded and somebody should be there to support you while you're getting your bearings. So that first week, it's really important to have somebody around. I would say the second week, you're not going to need the 24 hour kind of person around.

(09:02):
Now, it varies. People are different, different levels of toughness. I had a lady one time I did a body lift on, which is where you go all the way around instead of just doing the tummy in the front and it goes all the way around. And she said, well, I got a week off work. You think that'll be enough? I said, that's probably not enough time. And she's like, well, I only have a week and that's what I'm going to do. And I'm like, okay. I said, but I cannot promise you you're going to be feeling up to going to work in a week. And I did her surgery at the hospital. I'll never forget this because it just is one of those funny things. But anyhow, so that evening I went to check on her in the hospital and walked in her room and she was all sitting up in her bed and TV on and smile on her face. And she's like, I don't know what all the fuss is about, about this procedure. She goes, I told him to quit bringing me pain medicine. I'm good. And she definitely was back at work in a week.

Kirstin (09:57):
Are you serious?

Dr. Koehler (09:58):
Oh yeah. Yeah. I'm serious.

Kirstin (10:00):
Oh, I thought you were going to say the next day she was regretting it.

Dr. Koehler (10:03):
No, she was tough as nails, I'll tell you. But that is not typical. I would never tell somebody that that should be their expected recovery. But first week you need help. Second week you might need some help, but you're going to be able to get up on your own. You're going to be moving slow. I mean, yes, help would be beneficial, but not everybody's got the ability to have that person all day, every day. So plan on a week of having somebody and then two weeks would be ideal.

Kirstin (10:33):
No, I just was talking to a patient today that booked a tummy tuck and had questions and I said, Dr. Koehler is going to put lidocaine in your abdominal muscles and that first day you're not going to feel a thing. So get up out of bed and make a lap to the kitchen and back to your bedroom. That way you get up and move because that's going to help you in your recovery. You can't just lay in bed the whole time.

Dr. Koehler (10:55):
Yeah, no, actually we use a different anesthetic that we inject into the abdominal wall, but it does give you at least some extended pain relief. But even then you might get 24, 48 hours of pain relief, but at some point it's waking up.

Kirstin (11:15):
But if you get up and move, it's going to be better for you.

Dr. Koehler (11:17):
No, it's absolutely better if you move and if you are not up and moving, you will get a blood clot in your legs and that is a much bigger problem. So you got to get up and move. That's the big thing. That's the big concern. And a blood clot in your legs, although that's not good. It's serious. But that in and of itself is it's treatable. You have to be on a blood thinner, which of course if you've had a recent surgery, we really don't want you on a blood thinner. But the real big problem is if you get a clot in your leg and it goes to your lungs, that can be life-threatening.

(11:52):
And any woman who's had a C-section, they are getting you up and walking. You, you've been through this. If you've had kids, they're telling you, you got to get up and walk. Because any surgery that, especially abdominal surgery, and let me actually let say why this is so important. I know we're taking a tangent here, but I don't get

Kirstin (12:12):
Not you.

Dr. Koehler (12:12):
Yeah, I know, right? Like, breast surgery, I've never had a patient that had any kind of breast surgery that got a blood clot in their leg. I can never think of a time that that's happened. But I have had people that have had blood clots in their legs, and they are all either body lifts or tummy tucks. And for a couple reasons. One is we're tightening up those muscles like we talked about, and what that's doing is that's increasing your intra-abdominal pressure. We're pulling things tight.

(12:40):
It's increasing the pressure in your abdomen. Well, the blood has got to flow from your legs back to your heart, and if the pressure in your abdomen is increased, it's slowing down the ability of that blood to come back to your heart. So that's one of the things. And we are pulling the skin tight. And then if you're sitting in bed and you got your leg in such a position where the blood doesn't flow through the crease of your leg really well, it's kind of kinking off there. I mean, that's one more reason why the blood's not flowing back to the heart properly. And then you get a clot in your leg, you got blood that's stagnant sitting in your leg and it clots off. You just don't want that to happen. And really, I've not even had a patient with a blood clot in their leg for probably seven years. It's not common, especially because we do all these other things to help prevent that at surgery. And if you're doing your thing and you don't have any underlying, there's people that have clotting conditions that we aren't aware of. They didn't know they had a clotting problem. We didn't know they had a clot. And so there are things that can happen, but they're rare. They're really rare. So anyhow, sorry for the tangent, but that's what you got.

Kirstin (13:49):
Okay. I have another review because a lot of, well, actually, we kind of just talked about this, but a lot of your reviews mention pain or actually lack of it. So this one says, I had no problems at all with my procedure and did not experience the level of pain that I anticipated I would Now I feel good in my clothes and I do not have to hide behind layers of clothing and shapewear. I look amazing.

Dr. Koehler (14:12):
Yay.

Kirstin (14:14):
Oh my gosh, I love all these.

Dr. Koehler (14:16):
Yeah, that's good.

Kirstin (14:16):
So how do you make recovery comfortable for your patients? What do you do for pain?

Dr. Koehler (14:22):
Well, I mean there's a lot of little things that we do. We try to use some medicines that are not narcotic because we want them up and walking. We want people alert. We don't want 'em tired and sleepy and laying in bed. So there's different medicines that we use. And then really we do nerve blocks and other types of things at surgery so that we can at least get people home. They get their medicine in them, so they're not writhing in pain as the numbing medicines start to wear off their pain medicine is already kind of in place. And so yes, it's a gradual onset and they do feel discomfort. I mean, there's some procedures that really have essentially no discomfort, but things like a tummy tuck that's going to hurt. I mean, there's no way around that that's going to be uncomfortable, but there are things we can do to minimize it. And those are some of the things.

Kirstin (15:13):
Do you typically use drains in a tummy tuck?

Dr. Koehler (15:17):
Yes. And there were people that have touted drainless tummy tucks. And I can just tell you that those techniques, it's great if you're the person that you can get a drain less tummy tuck, but if I told you 20% of people had to get a drain put in after the fact, if you're in that,

Kirstin (15:36):
Is it a gimmick?

Dr. Koehler (15:37):
It's not a gimmick. It's just we haven't developed a technique to where I could do the tummy tuck and 99% of people would do just fine and not require any manual drainage or placement of a drain after the fact. It's just the nature of the procedure. I'll just tell you in my opinion, when it comes to abdominoplasty, if you come see me, you'll will get a drain. I know you will hate it. Nobody likes it. I don't want to put one in, but I promise you it's there for a reason and nobody likes to have to come to the office and get stuck with needles to get it drained manually. And if that was the situation, we didn't put a drain in, but now you got to come see me three times a week and I have to numb it up and stick a needle in and try to drain fluid it off. That's no good either. So yeah, there's lots of things that I do that we've in the past, maybe used drains, but now we do not use drains. We certainly try to move away from it. I just don't feel that the abdominoplasty is a procedure where we can predictably say we don't need a drain.

Kirstin (16:42):
Where does the drain go?

Dr. Koehler (16:43):
It's just between the skin and your abdominal muscles. It's not inside your abdomen. It sits underneath the skin where we've lifted the skin and fat up and it lays against the muscles. So it's on top of your muscles and between the muscles and the fat and the skin, that's where it sits. And the reason that it's there is that when we've elevated everything up and we have to mobilize things to be able to stretch that skin down so everything gets lifted up. Well, now things have to stick back down, but we've injected a bunch of local anesthesia and then just when your body pumps blood through those tissues, you get tissue fluid. And that tissue fluid normally would get brought back into your circulation through things called lymphatics, and you'll hear people getting lymphatic massage and we can talk about that. But basically those lymphatics are all disrupted when we do this surgery.

(17:37):
So they're not bringing the fluid back into your blood system. And so it builds up and there's a potential space where we lifted everything up. Now it has a place to accumulate, and if it builds up and you don't drain that fluid off, if it has nowhere to go, what will happen is the body will start to wall it off with scar tissue and it can create a problem creating what we call a pseudo bursa or this anyhow, this basically sack of scar tissue that then we have to come back and do another surgery to remove all the scar tissue and put another drain in. So anyhow, that's why the drain is there to make sure that fluid doesn't accumulate. Once your body's able to manage that fluid on its own and the drain's not filling up very much, then the drain can come out. Usually that's at a week. But in patients that are higher, BMI, they typically get their drains, they stay in a little longer, but it can happen to anybody. Some people, they have their drains for three or four weeks. That's not typical. Most people, the drain is in a week, maybe two.

Kirstin (18:41):
Do you usually recommend compression in the recovery period?

Dr. Koehler (18:44):
Yeah, we usually start off with an abdominal binder because that's easier to take on and off and to go to the bathroom and all that stuff. And if you have drain tubes like these garments, these fajas and all these garments that have snaps and clips and legs and all that stuff, yeah, some of them are crotchless and you can go to the bathroom, but some of them, if you got to go, taking those things on and off is really hard. And also the drains, there's not an easy place for the drains to come out. So we usually use an abdominal binder until your drains come out. And then we recommend some kind of a compression garment, like a Spanx or a Faja or whatever. There's different garments that you can get.

Kirstin (19:28):
Is there a certain amount of time you'd like people to wear that or not really?

Dr. Koehler (19:31):
Yeah, no. I mean, usually the first two weeks I like people to wear 'em 24 hours a day and you can take it off to shower or you can take it off to just take a quick break. But pretty much 24 hours a day for the first two weeks and then for the next two weeks, at least 12 hours a day. Now you could choose, like typically, I'd recommend during the daytime, because if you don't wear it during the day, and let's say you're up and walking, it's not unusual. People will say, or I've had people show me pictures, look, this is me when I woke up in the morning, and this is me when I got home at the end of the day. And it looks like two different people at the end of the day, they're like marshmallow. And at the beginning of the day, they look skinny and their waist looks great.

(20:13):
So again, your body's not able to handle that tissue fluid and you get that sort of swelling. So the compression just sort of helps with that during the day. And then at nighttime, you're laying down, so your body sort of reabsorbs that fluid. It goes back into your circulation. So two weeks halftime. The first two weeks is full-time wear. Next two weeks is halftime wear. Now you can wear compression longer than that, and some people choose to do that because it feels comfortable. Like that extra compression just makes them feel secure and comfortable. So I've had people wear compression for three months or longer. That's up to you. But I recommend for the first month, that's ideal, and compression is not going to make or break your result, but it definitely, it does, I think speed your recovery and I think it does help, so.

Kirstin (21:02):
When moms come in for these mommy makeovers and all is said and done and they're starting to heal and they're coming back for their post-ops, what sort of things do they say to you?

Dr. Koehler (21:14):
Lots of things.

Kirstin (21:15):
You're a magician. King of belly buttons.

Dr. Koehler (21:16):
Well, really the first four to six weeks is kind of a roller coaster ride for a lot of people that are getting this done. And it's not until it's typically around the three to four month mark where people are really realizing how good it is when you're swollen and not feeling great the first two, three weeks. Sometimes people are like, oh my God, what did I do? Why did I do this? I don't even know why I did this. Now I'm really questioning why I did this. But then when I see 'em at six weeks, most of the time people are like, oh my gosh, I'm really starting to see how this looks. And they like it, but they're still swollen. And common area that I routinely have to tell people is the pubic area especially will be swollen at six weeks.

(22:07):
People are like, I don't know. It looks bigger to me. I'm like, it's not bigger. It's swollen. We didn't do anything. We didn't put any fat there. We didn't graft anything. It's just swollen and it takes three to six months for the swelling to really fully resolve. So yeah, it's an emotional rollercoaster. They're not a hundred percent loving it, but usually by three, four months, people are like, they really can see the difference. And it's the one thing that I think can make a huge difference for a mom who's healthy and in good shape, but they don't feel sexy because they've got laxity and muscle separation. It's like they've got a great body, but then they don't. So this can really kind of put things back and it looks good.

Kirstin (22:55):
If you come back for your post-op and you look good and feel wonderful, we want to take pictures of you. And if you want us to share those pictures with the world, we would love to. So please.

Dr. Koehler (23:06):
Yeah, well, definitely. I always like to ask people to let us use their pictures, because inevitably people will come in. They're like, well, can you show me somebody that looks like me? I'm like, well, let's see what we got. I mean, people are built differently. And so the more people that I have that I can use as examples, I am sure that one day somebody's going to be like, that looks just like me. And that will help them make a decision of what they're wanting to do and what to expect.

Kirstin (23:39):
Love it. Do you have anything you want to add to mommy makeup recovery?

Dr. Koehler (23:42):
I mean, we can talk briefly about lymphatic massage you want.

Kirstin (23:45):
Oh, yeah.

Dr. Koehler (23:46):
Yeah. So we kind of mentioned about lymphatics. So the lymphatics are the things that bring the tissue fluid back into the circulation, into the bloodstream. And as you're healing, I mentioned these things can kind of get disrupted, and so you can get particular types of massages to where people are just very gently massaging your tissues in a way to where the lymph nodes sit and the lymph nodes are what really are the main collectors of that fluid. And so they're just trying to really help mobilize and get that tissue fluid out of the swollen areas and back into your circulation. And at first I was like, oh, I don't know if lymphatic massage really makes a big difference. And then you send some people to get it done, and all of a sudden they're like, man, they feel like it really makes a difference and enhances their recovery.

(24:42):
And so now the thing you need to know is that you can't just go to the Grand Hotel and go get your massage. I mean, lymphatic massage is a little different. It's not like deep tissue massage. It's not even really, I wouldn't even call it massage per se. It's a little different, but you need somebody that first of all knows what they're doing. And second of all, feels very comfortable with post-surgical patients because there will be massage people that they may know what it is, but they're afraid to touch you because they don't want to hurt you. They don't want to get in the middle of your, they don't, if something happens, they don't want to be blamed for it. So you need a massage therapist that feels comfortable with it, and there's people that we recommend. But lymphatic massage can be something that can maybe help speed up your recovery. It certainly feels good. And yeah, my experience is it does help, but it's an added cost, something that not everybody wants to do and the time involved too. So that's one more thing for recovery. What else do we want to talk about? Scar creams, scars?

Kirstin (25:49):
Oh yeah. We love scar cream.

Dr. Koehler (25:54):
Scar creams are good, but actually the thing I would just mention that, so how a scar heals, there are so many different factors that come into play. There's your genetics and all of that that you can't really control. But surgically, we want to clean surgical sites. So one of the things we encourage our patients to do is the night before and the morning of they wash with a Hibiclens soap to really decrease the bacterial content on their skin. It is so important. That's something that you need to do. It's not just like, oh, and it's not even necessarily infection. Yes, we don't want to get a surgical infection, but sometimes you can get just these little minor, not good healing wound edges that we could prevent. We just want to have a good clean surgical surface. So patients do that at surgery. I use the best suture that I can find.

(26:46):
There's some off name brands, and I'm not saying they're bad, but there are companies that are very reputable that have really good suture that I really like, and so we use really high quality suture. I think that's important in the healing process. And then how you take care of your dressings, and you know, each doctor may have different recommendations. So I'm not going to say what you should or shouldn't do. Listen to your doctor and what they say they want you to do with your dressings, but the dressing care is important. And then once we take those dressings off, we're going to have you typically put antibiotic ointment over your incisions for two or three weeks, and we want you to do that until the incision doesn't look maybe red or irritated. And sometimes it doesn't look like that at all. But we still are typically, it's not quite to the point where we want you to put scar cream on.

(27:36):
So for the first two weeks, antibiotic ointment, and then there's some scar creams, and yes, there's some over the counter. There's some that we sell at our office, and that's a whole nother discussion. But typically, the silicone based creams are what I like. I've used a number of different brands over the years. The one that I'm using now, I really like, but there's also silicone sheeting that you can do. We don't sell that in our office. You can buy that online. It has some pros and cons. Silicone sheeting works really well, and you lay the silicone gel sheet over your incisions, but it can get dirty. It's hard to keep it clean. Sometimes people kind of sweat underneath it. It's just so occlusive. So anyhow, but topical silicone is really the best thing for the scars. Most people, that's going to be sufficient. Keep your incisions clean.

(28:26):
Then use the scar cream when, and then you want to use that scar cream for three months. That's like the minimum timeframe that we'd recommend. You're going to do scar cream for three months. Then after that, I mean, you can continue to do it, but that's what we typically recommend a minimum. But for people that maybe have their genetics or such that they tend to get wider or thickened scars, there are other things we can do. We can do microneedling. We have lasers that can help with pigmentation and redness. So there's a lot of other options. You're not necessarily just because it's not healing. Ideally, you just got to throw your arms up and go, well, I guess that's it. There are things that can be done, but I would say for most people, we really don't need to do that. But if there's any questions or sometimes I have people that say, look, I don't care. What are my options? What can I do? I want my scars to look the best. I don't care what it's, we have lasers and microneedling and other things to help with that.

Kirstin (29:23):
We got stuff. All right. Do you have a burning question for Dr. Koehler or me? You can leave us a voicemail on our podcast website at Alabama the beautiful podcast.com. We'd love to hear from you. Thanks, Dr. Koehler. Go back to making Alabama beautiful.

Dr. Koehler (29:40):
Alright.

Announcer (29:41):
Got a question for Dr. Koehler? Leave us a voicemail at Alabama the Beautiful podcast.com. Dr. James Koehler is a cosmetic surgeon practicing in Fairhope, Alabama. To learn more about Dr. Koehler and Eastern Shore Cosmetic Surgery, go to eastern shore cosmetic surgery.com. The commentary in this podcast represents opinion and does not present medical advice, but general information that does not necessarily relate to the specific conditions of any individual patient. If you enjoyed this episode, please share it and subscribe to Alabama the Beautiful on YouTube, Apple Podcast, Spotify, or wherever you like to listen to podcasts. Follow us on Instagram at Eastern Shore Cosmetic Surgery. Alabama the Beautiful is a production of The Axis, THE AXIS. io.